Epidemiology:

Principles and Methods

Prof. dr. Bhisma Murti, MPH, MSc, PhD
Department of Public Health,
Faculty of Medicine, Universitas Sebelas Maret

Definitions in Epidemiology
1.
2.
3.

Definition and aims of epidemiology

Study designs used in epidemiology
Measures of Disease Frequency
Incidence (Cumulative Incidence and Incidence
Density)
Prevalence

4.
5.
6.
7.
8.

Measures of Association
Bias
Confounding
Chance
Causal Inference

Epidemiology
A study of the distribution of disease frequency
in human population and the determinants of
that distribution
Epidemiologists are not concerned with an
individuals disease as clinicians do, but with a
population distribution of the disease
Distribution of disease by person, place, time
Assumption:
Disease does not occur randomly
Disease has identifiable causes
which can be altered and therefore
prevent disease from developing

Definition of Epidemiology
The study of the distribution and determinants
of health-related states or events in specified
population, and the application of this study to
control of health problems.
[source: Last (ed.) Dictionary of Epidemiology, 1995]

Determinants: physical, biological, social,

cultural, and behavioral factors that influence
health.
Health-related states or events: health status,
diseases, death, other implications of disease
such as disability, residual dysfunction,
complication, recurrence, but also causes of
death, behavior, provision and use of health
services.

Aims of Epidemiologic
Research
1. Describe the health status of
a population
2. To assess the public health
importance of diseases
3. To describe the natural history
of disease,
4. Explain the etiology of disease
5. Predict the disease
occurrence
6. To evaluate the prevention
and control of disease
7. Control the disease
distribution

Descriptive
epidemiology

Analytic
epidemiology
Applied
epidemiology

Descriptive and Analytical

Epidemiology
1. Descriptive epidemiology

Describes the occurrence of disease (crosssectional)

2. Analytic epidemiology:

Observational (cohort, case control, crosssectional, ecologic study) researcher

observes association between exposure and
disease, estimates and tests it
Experimental (RCT, quasi experiment)
researcher assigns intervention (treatment),
and estimates and tests its effect on health
outcome

Epidemiologic Study
Designs

Epidemiologic Study Designs

Study Design and Its Strength

of Evidence
1. Systematic review, meta-analysis: Stronge
st
secondary data analysis
evidenc
2. Randomized Controlled Trials (RCT) e
3. Cohort: prospective or retrospective
Quasi experiment

4. Case control: prospective or

retrospective
5. Cross sectional
6. Case Reports / Case Series

Weakes
t
evidenc
e

Which Disease if More Important to

Public Health? Measure of Disease
Occurence

Hypothetical Data

Measles

Chickenpox Rubella

Children exposed
Children ill

251
201

238
172

218
82

Attack rate

0.80

0.72

0.38

Number of Ill persons (new cases)

Attack rate =
Population at risk exposed

Attack rate is a Cumulative Incidence; it shows the risk

(probability) of disease to occur in a population
In regard to risk, measles is the most important disease to
public health while rubella being the least

Description of Disease
Distribution in the
Population

Disease affects
mostly people
under five years
of age

Disease affects
people living
alongside the
river

Disease reaches
its peak in
frequency in
Week 6

Natural History of Disease

Transmission
Cases
Index the first case identified
Primary the case that brings the infection into a
population
Secondary infected by a primary case
Tertiary infected by a secondary case T
S

Susceptible
Immune
Sub-clinical
Clinical

P
S

S
T

Dynamics of
infectiousness
Susceptible

Infection

Timeline of Infectiousness
Latent
period

Infectious
period

Non-infectious

Dynamics of
disease
Susceptible

Infection

Time

Incubation
period

Symptomatic
period

Non-diseased

Time

Measure of Disease
Frequency
1.

Cumulative Incidence (Incidence, Risk, I, R)=

Number of new case over a time period
Population at risk at the outset
- Indicates the risk for the disease to occur in population at risk
over a time period. Value from 0 to 1.

2. Incidence Density (Incidence Rate, ID, IR)=

Number of new case over a time period
Person time at risk
Indicates the velocity (speed) of the disease to occur in population
over a time period. Value from 0 to infinity

3. Prevalence (Point Prevalence):

Number of new and old cases at a point of time
Population
Indicates burden of disease. Value from 0 to 1.

Number of Cases of a Disease

Endemic vs. Epidemic

Endemic
Time

Epidemic

Levels of Disease Occurence

Sporadic level: occasional cases occurring
at irregular intervals
Endemic level: persistent occurrence with a
low to moderate level
Hyperendemic level: persistently high level
of occurrence
Epidemic or outbreak: occurrence clearly
in excess of the expected level for a given
time period
Pandemic: epidemic spread over several
countries or continents, affecting a large
number of people

Factors Influencing Disease

Transmission
Agent

Environment

Infectivity

Weather

Pathogenicity

Housing

Virulence

Geography

Immunogenicity

Occupational setting

Antigenic
stability

Air quality

Survival

Food

Host

Age
Sex
Genotype
Behaviour
Nutritional status
Health status

Measures of Infectivity,
Pathogenecity, Mortality
Infectivity (ability to infect)
(number infected / number susceptible) x 100

Pathogenicity (ability to cause disease)

(number with clinical disease / number
infected) x 100

Virulence (ability to cause death)

(number of deaths / number with disease) x
100

All are dependent on host factors

Preventable Causes of
Disease
BEINGS

Biological factors and Behavioral Factors

Environmental factors
Immunologic factors
Nutritional factors
Genetic factors
Services, Social factors, and Spiritual
factors
[JF Jekel, Epidemiology, Biostatistics, and Preventive Medicine, 1996]

Types of Cause:
Necessary cause: Mycobacterium tuberculosis
Sufficient cause: HIV
Contributory cause: Sufficient-Component Cause

Causal Model of Risk Factors for

CVD
Morbidity and Mortality

(Stroke, MI)
Biological Risk Factors

Disease

Proxima
te cause

(Hypertension, Blood Lipids, Homocysteine)

Genetic Risk Factors

Behavioral Risk Factors

(Family History)

(Cigarette, Diet, Exercise)

Environmental Factors

(Socioeconomic Status, Work Environment)

Interme
diate
cause
Distal
cause

To Study Disease Etiology

Kuartil asupan buah dan sayur

Kuartil asupan buah dan sayur

To Study Prognosis
(Survival)

Validity of Estimated
Association and Causation
Smoking

Lung Cancer
OR = 7.3

True association
causal
non-causal

24

Bias?
Confounding?
Chance?

The Role of Bias, Confounding, and

Chance in The Estimated Association
Association ?
present

Selection Bias and

Information Bias?
absent

absent

present

False
association
likely

Confounding ?
unlikely
likely

Chance ?
unlikely
25

True association

BIAS
Systematic errors in selection of study
subjects, collecting or interpreting data
such that there is deviation of results or
inferences from the truth.
Selection bias: noncomparable procedure used to select
study subjects leading to noncamparable study groups in
their distribution of risk factors. Example: Healthy worker
bias
Information bias: bias resulting from measurement error/
error in data collection (e.g. faulty instrument, differential
or non-differential misclassification of disease and/ or
exposure status. Example: interviewer bias, recall bias)

Confounding
1. A mixing of effects

between the exposure, the disease, and a

third factor associated with both the
exposure and the disease
such that the effect of exposure on the
disease is distorted by the association
between the exposure and the third factor

2. This third factor is so called

confounding factor

Confounding
Observed (but spurious) association,
presumed causation

Birth Order

Downs
syndrome

Unobserved
association

True
association

Maternal age

Apakah Ada Hubungan antara

Urutan Kelahiran dan Risiko
Sindroma Down?

Confounding

[Biomedical Bestiary: Michael, Boyce & Wilcox, Little Brown. 1984]

Observed (but spurious) association,

presumed causation

Gambling

Unobserved
association

Cancer
Smoking,
Alcohol,
other
Factors

True
association

Hills Criteria for Causation

1.
2.
3.
4.
5.
6.
7.
8.
9.

Strength of association
Specificity
Temporal sequence
Biologic gradient (dose-response relationship)
Biologic plausibility
Consistency
Coherence
Experimental study
Analogy